Patient Information (Page 4 of 4) in pdf

Patient Information Page 4

Medical Information Release Form/Designation of Personal Representative

(HIPAA Release Form)

You may designate a personal representative who may act in your behalf of making decisions relating to health care, which includes

treatment and payment issues. This individual can be a family member, friend, lawyer or unrelated party.

Please print neatly to ensure correct and prompt processing. We reserve the right to return any illegible or incomplete form.

[ ] I authorize the release of information including diagnosis, records, examinations rendered to me and claims and payment

information. This information may be released to:

[ ] Spouse: ____________________________________

[ ] Child(ren): __________________________________

[ ] Other: _____________________________________

This Release of Information will remain in effect until terminated by me in writing.

Messages

Please call

[ ] my home

[ ] my work

[ ] my cell phone

If unable to reach me:

[ ] you may leave a detailed message

[ ] please leave a message asking me to return your call

[ ] ___________________________________________

The best time to reach me is: (day) ________________________ between (time) __________________________

Signed: _______________________________________________ Date: ___________________

Witness: ______________________________________________ Date: ___________________

Patient Information Page 4